SNFs Face New CMS Five-Star Challenges Amid Covid-19

Updated: Jan 31



Operating a skilled nursing facility has become a significant challenge in the last two years. It is almost as if COVID-19 and its effect on the workforce never happened, at least for the folks at CMS. The bottom-line: getting and keeping that coveted 5-Star rating has become much more difficult.


Mercifully, CMS was a little easier on everyone as the first and second waves of Covid-19 swept across the country. Skilled nursing facilities (SNFs) were especially hard hit, and CMS had a difficult time getting the personnel out for their regularly scheduled inspections and the surprise visits. Nevertheless, some facilities were dutiful in their self-reporting responsibilities, even if reports came in late.


They might have made it look too easy. In January 2021, while still in the grips of the second wave, CMS announced that surveys conducted after 2020 would be included in the health inspection rating and citations from focused infection control surveys, the CMS reporting required of SNFs with Covid-19 outbreaks, would be included in the rating calculation.


More from CMS


Then in January of this year, CMS announced that it would begin posting SNF staff turnover rates and weekend staffing levels on Medicare’s Care Compare site this month. This, as the hyper-contagious wave of the Covid-19 omicron variant is decimating workforces across the country, including SNF labor pools, which have already been under immense pressure.

Then came the next blow for 2022. That same information on staffing turnover and staffing levels would be incorporated into the CMS five-star rating for SNFs starting in July.


There May Be Some Unanticipated Surprises


At least one source thinks that these new edicts by CMS might bring some industry problems to light.


“I do think longer term this data will add value and can serve as a signal to all of us that we need to invest more in direct care staff,” said David Grabowski, professor of healthcare policy at Harvard Medical School. Grabowski was speaking during a LeadingAge call with industry stakeholders, as reported by McKnight’s Long-Term Care News. “We get the turnover we pay for, and since we aren’t paying enough, we’re seeing high turnover. That’s not something nursing homes can fix on their own. I really believe we need more reimbursement from Medicaid and Medicare to make that happen.”


A Quick Look at the 5-Star Rating


Medicare rates SNFs on a five-star system, five being the highest rating and one being the lowest. The ratings are based on three categories of criteria: inspections, staffing, and quality. The highest weight is given to inspections, counting for half of the overall rating, according to an article posted by The GreenFields, a continuing care community-based in New York and part of the Niagara Lutheran Health System. Staffing and quality are given lesser weight in the score. Staffing and quality are also self-reported, but Medicare does audit some facilities to keep them honest, and word is that the audits are on the upswing.


The scores for any year also take into consideration the scores for that year (given the most weight) as well as scores for the previous two years. CMS recently announced that those facilities which were not inspected in 2020 would have their score based on the last two years, with the current year’s score getting 60% of the weight and the remaining 40% based on the previous year’s score.


The top ten percent of facilities achieve the five-star status. The bottom twenty percent are given one star. The remaining 70% are ranked in the middle, earning two, three, or four stars depending on where they fall.


There is one bright spot in this scoring system. All scores are rated against the scores of other facilities, which essentially means that grading is on the curve.


Scores Are Considered by More than Just the SNF Customers and Families


The CMS rating carries a good deal of weight beyond just the ability to show that five-star rating. Consider:

  • Other regulatory agencies often consider the state and local scores’ scores for the issuance of licenses, permits, and other filings.

  • Doctors consider the ratings when determining where a patient should go after leaving the acute-care hospital when they may require additional recovery time after a bypass or hip replacement.

  • Several Medicaid plans will not accept SNFs with less than a three-star rating, and insurers consider the scores when setting up care networks.

  • Medicare will allow waivers of the required three-day hospital stay if the individual is going to an SNF with at least a three-star rating.

  • A SNF’s score will also be considered by the Department of Housing and Urban Development when evaluating a loan. Some other lenders and institutional investors also consider the ratings when compiling their underwriting checklist.

Ways to Ensure Success in Your SNF’s CMS Rating


You can do some things to help ensure a successful CMS ranking. One of these is to hire at least one individual intimately familiar with the CMS procedure and how it works. During their inspections, CMS gives the most weight to conditions that could potentially result in injuries to residents. Someone familiar with what CMS looks for will spot these hazards and have them remedied immediately.


As reported by Sean Fahey, an attorney with Hall Render, a law firm specializing in health-related matters, the Department of Health and Human Services Office of the Inspector General (OIG) “publishes monthly updates to its Work Plan to describe OIG’s new and continuing audit and enforcement priorities. These updates, along with the existing priorities already in the Work Plan, are useful for SNFs to identify compliance program risk areas, improve policy development and manage audit and other risk management efforts.”


Employee training is another area. The leadership at your SNF must always be vigilant of issues. Reducing the number of resident falls will be reflected in your quality ratings. Readmissions are also an issue (check out this CareWork blog to help your staff cut down on unnecessary readmissions).


Don’t Forget to Watch the Data.


Staffing and quality are both a large part of health inspection success. Your data tells a story and outlines a roadmap for improvement.


When determining staffing ratings, CMS looks at the average number of care hours provided to each resident every day by the direct care staff. CMS uses your payroll-based journal reports (PBJ) to make this determination. Per-patient-day measurements (PPD) play a big part in winning stars. Not just for staffing but quality as well. Because resources are slim right now, it’s important for measuring, maintaining, and reporting staffing levels to be as simple as possible, and now that CMS is reporting on turnover rates, it’s essential that SNFs keep a constant eye on the turnover and retention in their facilities.


CareWork makes it easy to proactively manage direct care staffing levels based on state-specific requirements and company targets without spending undue time or allocating additional resources. CareWork gives you the information you need to manage to the staffing levels you need as your census changes, so you have the right number of people in the right shifts and are not paying unneeded overtime.


CareWork helps you manage your RN Staffing Rating as well. RN hours are tracked and applied correctly, including Director of Nursing RN hours when the SNF has an average daily census of sixty or fewer residents.


Turnover reporting can be done at the click of a button by location and down to the department and job title, making it easy to track the impact of changes implemented to improve retention rates.


Quality measures are another set of data SNFs are watching closely for five-star success. Comparing the actual long and short-stay quality measures attainment against company targets, state averages, and national averages daily, weekly, and monthly helps clinical teams stay in front of quality areas that need improvement before the next rating cycle. Watching trends in QM percentages also tells a story. Do we have adequate coverage, training, and process?


CareWork is the only operational platform designed specifically for skilled nursing operators and senior care providers. We help make the most out of the systems you already use and tie your data together to give you a single source of truth. Through a single login, care, financial, and operational teams have access to descriptive analytics, including historical, current, and trending information. This comes in handy when you are in the pressure-paced atmosphere of having a surveyor walk in the door. Automated and assignable tasks, communication, and workflow in one place streamline the way long-term and senior care companies operate.


CareWork saves time and gives your staff the insight they need to do a great job. We make care work easier.


Ready to work more efficiently and get that five-star rating? If so, contact us at CareWork today.


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